Referral, interrupted: GP faces resistance from veterinary oncologist

Veterinary medical expertise is growing by leaps and bounds. Veterinary specialists are now commonplace and primary care clinicians use their services frequently to supplement and support their diagnoses. This was the case when Dr. Linda Canto discovered that one of her patients had lymphoma.

Dr. Canto had done a full workup and had the lab evaluate a lymph node aspirate. She had seen many cases like this, but due to the gravity of the diagnosis she always sent these dogs to an oncologist for a second opinion. Dr. Canto wanted to make sure she had not missed anything and that her recommendations were consistent with those of the specialist.

In this instance, the pet owners appreciated the referral and promptly made an appointment with Dr. Gerald Folk, a boarded oncologist at a nearby specialty hospital. All of the radiographs and lab work were forwarded to the oncologist before the pet's appointment. The owners were happy with their visit and were pleased that Dr. Folk and Dr. Canto agreed on the diagnosis. Dr. Folk recommended an initial eight-week course of chemotherapy. The owners opted to have their family veterinarian administer the chemotherapeutic protocol and planned to touch base with the oncologist after each treatment cycle.

Dr. Canto received the specialty center's referral report, in which Dr. Folk recommended one of two similar treatment protocols for the pet's lymphoma. The letter was not specific about the exact chemo protocol parameters, so Dr. Canto had her chief technician call Dr. Folk and ask him to forward his treatment of choice and dosage recommendations. But Dr. Folk refused, telling the technician that the information was available in reference texts or via online access.

This disturbed Dr. Canto. She understood that the specialty center would have liked to do the treatment for this pet. Nevertheless it was her referral, and she was simply seeking a second opinion. She believed the role of the referral specialist was to evaluate the patient and report all pertinent findings and treatment recommendations. In her opinion, Dr. Folk was being retained to give the client and referring veterinarian all the expert information his training had provided. He was certainly not supposed to withhold specific treatment protocols in the hope that treatment would take place at the specialty center.

It was time for Dr. Canto to call Dr. Folk personally. The discussion was professional but direct. Dr. Canto said she expected a referral report to assist her as much as possible, and her request for his suggested chemotherapy protocol and its specifics should not have been met with resistance. Dr. Folk thanked Dr. Canto for her many referrals and apologized for any misunderstanding. He stated that he always attempted to be as helpful as possible. Dr. Canto then said tactfully that in this case he had not been as helpful as possible and hoped it would not happen again in the future.

After ending the call Dr. Canto felt she had resolved the issue but unfortunately believed she needed to be on guard in the future. She now had to be aware that certain specialty consultants might be conflicted when it came to returning the patient to the referring generalist. They might encourage the pet owner to continue treatment at the specialty facility.

Do you think Dr. Canto overreacted, or was the specialist not fulfilling all of his referral obligations?

Rosenberg's response

Dr. Canto did not overreact. Today progressive practices utilize boarded oncologists, surgeons and dermatologists on a regular basis. We owe it to the client to offer specialty consultations when presented with these challenging cases.

The fact of the matter is that fees associated with treating orthopedic and neoplastic diseases can be quite high, and specialty centers need revenue just like any other business. Therefore it's tempting for a specialist to encourage a referred client to continue treatment at his or her own facility. This temptation must be resisted. It's unethical and, from a practical point of view, will discourage future referrals if the generalist feels he or she may lose a client.

Unfortunately, this type of conflict is on the rise as the number of specialty facilities grows. There should be no issues as long as the referring clinician and specialist cooperate in an ethical and professional manner. However, in the less-than-perfect world we live in, the referring veterinarian must scrutinize specialty referrals closely.

Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, N.J. He is a member of the New Jersey Board of Veterinary Medical Examiners. Although many of his scenarios in “The Dilemma” are based on real-life events, the veterinary practices, doctors and employees described are fictional.